RESUMEN
BACKGROUND: Gastrostomy tube (GT) dislodgement is a common reason for emergency department (ED) visits. We aim to assess the efficacy of our institution's algorithm in reducing surgical consultation and GT contrast studies for replacement of dislodged GT and to examine the need for operation before and after algorithm implementation. METHODS: A retrospective review was performed between March 2017-February 2018 (prealgorithm) and March 2018-December 2018 (postalgorithm) for patients <18 years presenting to the ED with GT dislodgement. Demographics and outcomes were analyzed. RESULTS: A total of 433 visits among 279 patients were included, 200 (46.2%) pre and 233 (53.8%) postalgorithm implementation. Median ED LOS was 2.1 h (IQR 1.4, 3.0). Surgery was consulted in 92 visits (21.3%) and a contrast study obtained in 287 (66.3%). The GT was replaced by ED providers in 363 visits (83.8%) and by surgery in 70 (16.2%). Surgical consultation increased postalgorithm (16.5% vs. 25.3%; p = 0.03). Six (1.4%) patients required reoperation, with 5 occurring postalgorithm, p = 0.22. For GTs placed < 8 weeks prior to the dislodgment, there were no differences in surgical consultations, contrast studies performed, or need for reoperation pre and postalgorithm. CONCLUSION: An algorithm for replacement of dislodged GT is usable, effective, and increased surgical team involvement without significant changes in patient outcomes. TYPE OF STUDY: Treatment Study. LEVEL OF EVIDENCE: Level III.
Asunto(s)
Servicio de Urgencia en Hospital , Gastrostomía , Algoritmos , Humanos , Reoperación , Estudios RetrospectivosRESUMEN
OBJECTIVES: The objective of this study was to evaluate ordering of albuterol via metered-dose inhaler with spacer (MDI-spacer), length of stay (LOS), and 72-hour return rates before and after publication of an internally developed pediatric asthma clinical practice guideline (CPG). METHODS: The internally developed CPG reflected national recommendations. It was explained at faculty meetings by a respected clinician and published on the intranet on February 6, 2012. We performed a retrospective study of visits from January 1, 2009, to October 31, 2014, by children aged 2 to 17 years with a primary diagnosis of asthma and discharged from a target site (2 pediatric emergency departments and 1 urgent care center). We excluded critical/emergent visits and those by patients who transferred to the emergency department/urgent care center from another facility or were admitted. We extracted data for 37 months before and 33 months after CPG implementation (post-CPG) using a single electronic health record system. RESULTS: Albuterol delivery via MDI-spacer increased by 33.95% (P < 0.0001) during 1-month post-CPG implementation with no significant subsequent decrease. An unexpected decline was noted for median LOS before CPG implementation (-1.24 minutes; P < 0.0001). For MDI-spacer-treated patients post-CPG, decreased median LOS was maintained and there was decreased variability of the median LOS (P < 0.001). For nebulizer-treated patients post-CPG, median LOS increased (.95 minutes; P = 0.033). No change was observed for 72-hour return rates. CONCLUSIONS: Implementation of an asthma CPG increased ordering of albuterol via MDI-spacer. The increase was sustained over time in all study sites. Decreased variability in median LOS for MDI-spacer patients was observed post-CPG. Median LOS for those treated with MDI-spacer exclusively remained unchanged in the post-CPG period, whereas post-CPG LOS increased in those who received nebulized albuterol.
Asunto(s)
Albuterol/administración & dosificación , Asma/tratamiento farmacológico , Broncodilatadores/administración & dosificación , Aceptación de la Atención de Salud/estadística & datos numéricos , Adolescente , Instituciones de Atención Ambulatoria/estadística & datos numéricos , Niño , Preescolar , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Inhaladores de Dosis Medida , Readmisión del Paciente/estadística & datos numéricos , Guías de Práctica Clínica como Asunto , Estudios RetrospectivosRESUMEN
OBJECTIVE: This study aimed to measure interexaminer agreement for physical examination (PE) findings in children with a suspected soft tissue abscess. METHODS: A prospective study was conducted from March 1 to July 31, 2007, at an urban, tertiary care children's hospital emergency department. Children presenting to the emergency department with a suspected local skin abscess were independently examined by 2 physicians. Interrater agreement of 7 PE findings for children with a suspected soft tissue abscess was assessed. Interrater agreement was calculated for the diagnosis of the lesion and decision to incise and drain. RESULTS: A total of 105 paired observations were completed by a total of 27 physicians. The patients examined were aged 2 weeks to 18 years, with a mean age of 80 months. Lesions were most frequently encountered on the buttocks (38%). Incision and drainage was attempted in 75% of cases, with purulent material obtained in 92% of all attempts. Interrater agreement was substantial for erythema (κ = 0.66) and size of the lesion (intraclass correlation coefficient = 0.78), moderate for drainage (κ = 0.57) and tenderness (κ = 0.40), fair for fluctuance (κ = 0.35), and poor for warmth (κ = 0.15) and showed no agreement for induration (κ = -0.08). There was moderate agreement on diagnosing the lesion as an abscess (κ = 0.48) and determination if the lesion required incision and drainage (κ = 0.44). CONCLUSIONS: Interexaminer agreement of examination findings and diagnosis of an abscess was fair to moderate, implying a lack of precision of PE as the primary means for diagnosis. Future studies of diagnostic adjuncts, such as bedside ultrasonography, may lead to improved management of soft tissue infections in children.
Asunto(s)
Absceso/diagnóstico , Examen Físico/normas , Infecciones de los Tejidos Blandos/diagnóstico , Absceso/cirugía , Adolescente , Niño , Preescolar , Estudios Transversales , Diagnóstico Diferencial , Drenaje , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Variaciones Dependientes del Observador , Estudios Prospectivos , Reproducibilidad de los Resultados , Infecciones de los Tejidos Blandos/cirugíaRESUMEN
STUDY OBJECTIVE: We compare percentage of healing, comfort, and complications in children with corneal abrasions treated with an eye patch versus no eye patch. METHODS: We performed a randomized clinical trial of patients aged 3 to 17 years who were diagnosed with isolated corneal abrasion. Patients were randomly assigned to an eye patch or no patch group. Abrasion size was documented with digital photographs and/or an eye template diagram at presentation and at 20- to 24-hour follow-up examination. A reviewer masked to treatment group determined percent healing by measuring presentation and follow-up abrasion sizes on the photographs/template. At follow-up, interference with activities of daily living (ADL) was measured with a visual analog scale and the number of pain medication doses taken since presentation was recorded. RESULTS: A total of 37 patients were enrolled: 17 with an eye patch and 18 with no eye patch. The mean patient age was 10 years, and two thirds of the patients were male. The majority (86%) of patients had 95% or more healing at follow-up, and there was no significant difference in percent healing between the 2 groups, even when adjusted for age and initial abrasion size (95% confidence interval [CI] for the difference in means -11 to 8 and -13 to 5, respectively). There was no difference between groups for number of pain medication doses required. Among measurements of interference with ADL, only the difficulty walking score was found to be significantly different between groups (patch mean 1.7 cm [SD 2.1 cm] versus no patch mean 0.3 cm [SD 0.7 cm]; 95% CI for the difference in means 0.3 to 2.5). CONCLUSION: This study suggests that eye patching in children with corneal abrasions makes no difference in the rate of healing. There was no difference in discomfort and interference with ADL, other than greater difficulty walking in the patch group, and there were no complications in either group.